Now, let’s look at the activities prescribed for her VOR dysfunction. 

Quick Recap: 44-year-old female with dizziness post-vestibular neuritis (click here if you missed the 5-visit central-peripheral integration progression focusing on the patient’s symptoms of dizziness in busy visual environments, AKA: Visually Induced Dizziness) 

• PMH: previous concussions w/o LOC; migraines (not since mid 30’s); motion sickness as a child but not as an adult
• Denies otologic symptoms, previous spells of vertigo
• Rates health as excellent
• Previous Diagnostics: imaging normal in ED; hearing WNLs; VNG with 28% right caloric weakness
• Symptoms: no longer spinning but dizziness exacerbated by busy visual environments and quick head movements and turns; sometimes feels “drunk-like”; eye fatigue; decreased concentration

Summary of Initial Eval Findings

• DHI Screen: 22/40
• Neuro Screen: normal (tone; coordination; smooth pursuit and saccades)
• Gross MMT: WNLs
• Gross ROM: WNLs for UE/LE. Cervical ROM: WNLs with reports of “tightness” at end range rotation.
• Eye ROM: WNLs; Ocular Alignment: (+) esophoria bilat with right > left;
• Vergence: Impaired eye teaming (NP convergence) – left eye breaks at 14 cm
• Static Balance: normal for tandem, single leg stance, and Romberg on firm. Romberg on foam x 14 sec
• Functional Gait Assessment: 24/30

Remember, the activities are not part of a protocol but based on a theoretical framework of VOR training and neuroplasticity. And taking full advantage of the exciting research about novel ways to perform gaze stabilization training. 

These exercises were designed to alleviate her residual movement-related symptoms, especially those associated with head movements, quick turns, etc. 

You will see that we started in a seated position and eventually progressed into standing positions although we alternated between the two positions based on how her activities were changed. 

Our Challenges

• Poor understanding of physiology of how “VOR improves”
• Studies show VOR x 1 does not change the VOR gain (adaptation), suggesting VOR ex x 1 are habituation exercises or central compensation – not adaptation (Benett et al., 2017; Micarelli et al., 2017)
• Lack of consistency on duration, frequency, distance, and static vs incremental
• Clinical Practice Guidelines (CPGs) differ than research showing optimal duration for VOR gains (15 min; in the dark; toward the affected side; incremental) (Migliaccio and Schubrt,2013-14; Rinaudo et al., 2018-19 and 2021; Todd et al, 2019)
• Historically, recommended between 2-10 feet but more recently, it has been shown VOR gain improves more with convergence (15 cm) (Chang & Schubert, 2021)

Take Home Messages

• Sinusoidal VOR x 1 does work – patients/clients perform better on DVA and subjectively. Frequency needs to be a minimum of 1.3 Hz.
• Consider applying these newer VOR training recommendations:
• If you know there is a hypofunction on 1 side, try small, rapid head impulses (~3 Hz) to that (affected) side
• Try VOR in the dark – it decreases visual stimuli in the room allowing for more attention on the task at hand and the laser provides contrast…contrast is important
• Consider trying sinusoidal VOR x 1 either with the target in near point convergence range (15 cm) and progress to performing VOR x 1 while repeatedly moving the target from arm’s length away to NPC and back out

• Share your story…research and clinical

Next…

A Sample Program on Progression of Multisensory Balance Training